Publications by authors named "Aakriti R Carrubba"

12 Publications

  • Page 1 of 1

Impact of Legislation on Opioid Prescribing following Hysterectomy and Hysteroscopy in Arizona and Florida.

Gynecol Obstet Invest 2021 Oct 12:1-9. Epub 2021 Oct 12.

Division of Gynecologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Objectives: This study aimed to determine the oral morphine equivalents (OMEs) prescribed and refill rates following hysterectomy and hysteroscopy in the setting of opioid prescribing practice changes in 2 states.

Design: This is a retrospective cohort analysis consisting of 2,916 patients undergoing hysterectomy or hysteroscopy between July 2016 and September 2019 at 2 affiliated academic hospitals in states that underwent legislative changes in opioid prescribing in 2018.

Methods: Participants were identified using the Current Procedural Terminology procedure codes in Arizona and Florida. Hysterectomy was chosen as the most invasive gynecologic procedure, while hysteroscopy was chosen as the least invasive. Medical records were abstracted to find opioid prescriptions from 90 days before surgery to 30 days after discharge. Patients with opioid use between 90 and 7 days before surgery were excluded. Prescriptions were converted to OMEs and were calculated per quarter year. Statistical analysis included Wilcoxon rank sum t tests for OMEs and χ2 t tests for refill rates. Interrupted time-series analysis was used to determine significant change in OMEs before and after legislative change. Statistical analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC, USA).

Results: In Arizona, 1,067 hysterectomies were performed; 459 (43%) vaginal, 561 (52.6%) laparoscopic/robotic, and 47 (4.4%) abdominal. There were 530 hysteroscopies. Overall median OMEs decreased from 225 prior to July 2018 to 75 after July 2018 (p < 0.0001). The opioid refill rate remained unchanged at 7.4% (p = 0.966). In Florida, there were 769 hysterectomies; 241 (31.3%) vaginal, 476 (61.9%) laparoscopic/robotic, and 52 (6.8%) abdominal. There were 549 hysteroscopies. Overall median OMEs decreased from 150 prior to July 2018 to 0 after July 2018 (p < 0.0001). The opioid refill rate was similar (7.8% before July 2018 and 7.3% after July 2018; p = 0.739).

Limitations: Limitations include involvement of a single hospital institution with a total of 10 fellowship-trained surgeons and biases inherent to retrospective study design.

Conclusions: Legislative and provider-led changes coincided with decreases in opioid prescribing after 2018 in both states without increasing rates of refills and showed actual data reflected in the medical record. Gynecologists must actively participate in safe prescribing practices to decrease opioid dependence and misuse.
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October 2021

Association of coccygodynia with pelvic floor symptoms in women with pelvic pain.

PM R 2021 Sep 17. Epub 2021 Sep 17.

Department of Medical and Surgical Gynecology, Mayo Clinic, Jacksonville, Florida, USA.

Background: Coccygodynia is a painful condition of the tailbone that occurs more commonly in females. The association of coccyx pain with pelvic floor symptoms and the prevalence of coccyx pain in women with pelvic pain has not previously been reported.

Objective: To identify the prevalence of coccygodynia in women with pelvic pain and to describe the association of coccygodynia with pelvic floor examination findings and symptoms.

Design: Retrospective cohort analysis.

Setting: Tertiary medical institution.

Participants: One hundred twenty-seven women presenting for outpatient pelvic floor physical therapy treatment who underwent vaginal and rectal pelvic floor examination.

Main Outcome Measures: Prevalence of coccygodynia, pain scores, association of coccygodynia with other comorbidities and diagnoses, and association of coccygodynia with physical examination findings.

Results: Sixty-three (49.6%) of 127 women with pelvic pain presented with coccygodynia and 64 (50.4%) did not. Women with coccygodynia had significantly higher rates of muscle spasm (50.8% vs. 31.2%, p = .025) higher visual analog scale pain scores (median 5 vs. 3, p = .014), higher rates of outlet dysfunction constipation (31.7% vs. 10.0%, p = .032), and higher rates of fibromyalgia (15.9% vs. 3.1%, p = .014). On pelvic examination, women with coccygodynia were significantly more likely to have sacrococcygeal joint hypomobility (65.1% vs. 14.1%, p < .001), coccygeus muscle spasm (77.8% vs. 17.2%, p < .001), anococcygeal ligament pain (63.5% vs. 9.4%, p < .001), external anal sphincter pain/spasm (33.3% vs. 13.1%, p < .001), and impaired pelvic floor muscle coordination (77.8% vs. 57.8%, p = .016).

Conclusions: Almost 50% of women seeking pelvic floor physical therapy for pelvic pain had coexisting coccygodynia. These women had higher pain scores, increased pelvic floor dysfunction, and significantly greater abnormal physical exam findings. This study demonstrates a strong link between coccygodynia, pelvic floor symptoms, and pelvic pain and highlights the importance of screening for and identifying coccyx pain when evaluating women with pelvic pain.
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September 2021

Laparoscopic Transillumination for Extrapelvic Superficial Abdominal Wall Endometriosis.

J Minim Invasive Gynecol 2021 Jul 5. Epub 2021 Jul 5.

Department of Medical and Surgical Gynecology, Mayo Clinic, Jacksonville, Florida (all authors).

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July 2021

Use of Cannabis for Self-Management of Chronic Pelvic Pain.

J Womens Health (Larchmt) 2021 09 16;30(9):1344-1351. Epub 2020 Nov 16.

Department of Gynecologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Chronic pelvic pain (CPP) affects up to 15% of women in the United States. The endocannabinoid system is a potential pharmacological target for pelvic pain as cannabinoid receptors are highly expressed in the uterus and other nonreproductive tissues. We hypothesize that cannabis use is common for self-management of CPP, and our primary objective was to determine the prevalence of cannabis use in this population. A cross-sectional survey of women with pelvic and perineal pain, dyspareunia, or endometriosis was performed between March and August 2019. Subjects were recruited in an outpatient gynecology office. An anonymous, confidential, electronic survey was performed using a tablet. Statistical analysis was performed using JMP (SAS, Cary, NC). A total of 240 patients were approached, with 113 responses (47.1% response rate). There were 26 patients who used cannabis (23%). The majority used at least once per week ( = 18, 72%). Most users ( = 24, 96%) reported improvement in symptoms, including pain, cramping, muscle spasms, anxiety, depression, sleep disturbances, libido, and irritability. Over one-third (35%) stated that cannabis use decreased the number of phone calls or messages sent to their provider, and 39% reported decreased number of clinical visits. Side effects, including dry mouth, sleepiness, and feeling "high," were reported by 84% ( = 21). Almost one-quarter of patients with CPP report regular use of cannabis as an adjunct to their prescribed therapy. Although side effects are common, most users report improvement in symptoms. Our study highlights the potential of cannabis as a therapeutic option for patients with CPP.
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September 2021

Association of uterine dimensions and route of contained morcellation following laparoscopic hysterectomy.

Minerva Ginecol 2020 Oct 17;72(5):316-324. Epub 2020 Jul 17.

Department of Gynecologic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA.

Background: The aim of this study was to determine if uterine dimensions on preoperative imaging are associated with route of contained morcellation during laparoscopic hysterectomy.

Methods: This is a prospective cohort study of patients undergoing laparoscopic hysterectomy and requiring morcellation for specimen extraction from March 2017 through August 2019. A contained extraction system was inserted and manual morcellation was performed vaginally, abdominally, or via a combination of both methods in cases of failed vaginal extraction.

Results: A total of 47 patients were treated. Median age was 47 (range 38-70). Morcellation was performed vaginally for 29 patients (61.7%), abdominally for 13 patients (27.7%), and via combined approach for 5 patients (10.6%). The combined group had the highest frequency of patients who were black (vaginal: 24%, abdominal: 31%, combined: 100%; P=0.005), the longest median total operating time (vaginal: 167 minutes, abdominal: 183 minutes, combined: 268 minutes; P=0.006) and the longest median time of uterine morcellation (vaginal: 14 minutes, abdominal: 37 minutes, combined: 85 minutes; P<0.001). There was strong evidence of a positive correlation with time of uterine morcellation for both largest uterine diameter (Spearman's r: 0.62, P<0.001) and uterine volume (Spearman's r: 0.70, P<0.001). These associations remained consistent after multivariable linear regression models that were adjusted for route of morcellation, hysterectomy type, and BMI (both P<0.001).

Conclusions: Larger uterine dimensions are associated with increased total operating and morcellation times. Uterine size and volume on preoperative imaging were not associated with route of morcellation, but there was a trend towards failed vaginal extraction when uterine dimensions exceeded 16 centimeters.
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October 2020

Transvaginal Enterocele and Evisceration Repair After Radical Cystectomy Using Porcine Xenograft.

Female Pelvic Med Reconstr Surg 2020 07;26(7):e19-e22

Department of Gynecologic Surgery, Mayo Clinic, Jacksonville, FL.

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July 2020

Factors Associated with Burnout and Frustration among Minimally Invasive Gynecologic Surgery Fellows.

J Minim Invasive Gynecol 2021 01 28;28(1):75-81. Epub 2020 Mar 28.

Department of Gynecologic Surgery (Drs. Jijon, Carrubba, Destephano, and Dinh), Mayo Clinic Florida, Jacksonville, Florida.

Study Objective: Determine the prevalence of burnout and frustration among participants currently completing a fellowship in minimally invasive gynecologic surgery (FMIGS).

Design: Cross-sectional survey.

Setting: An anonymous survey was distributed to fellows in November 2018.

Participants: Current FMIGS fellows.

Interventions: Not applicable.

Measurements And Main Results: A total of 57 of 83 (67.7%) FMIGS participants in American Association of Gynecologic Laparoscopists-accredited programs completed a survey regarding fellowship characteristics and experiences. Overall, 40 participants (70.2%) indicated that they were satisfied with their fellowship program experience. There were 33 participants (57.9%) who reported burnout, and 38 participants (66.7%) had experienced anxiety, depression, or extreme fatigue during the last month. Of those who reported burnout, 26 (76.5%) reported that they did not receive support from their fellowship program. Participants who experienced burnout were more likely to be in their second year (p = .003), spent less time per week doing scholarly activities (p = .048), and were less satisfied with their fellowship experience (p <.001). Participants who experienced anxiety, depression, or extreme fatigue had more cofellows in their program (p = .031), worked on average more hours per week (p = .020), and were more often required to practice obstetrics in their fellowship (p = .022).

Conclusion: Burnout symptoms are common among physicians across multiple specialties. Our findings suggest that this issue is prevalent among FMIGS participants. In addition, there is a lack of access to emotional and psychologic support programs for fellows experiencing burnout. We hope that this study will prompt attention to this important topic by both individual programs and American Association of Gynecologic Laparoscopists as a society to increase awareness and access to resources and promote wellness for fellows.
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January 2021

Variability between individual surgeons in route of hysterectomy for patients with endometrial cancer in Florida.

Surg Oncol 2019 Dec 12;31:55-60. Epub 2019 Sep 12.

Mayo Clinic Department of Surgical Gynecology, Jacksonville, FL, USA.

Objectives: Minimally invasive surgery (MIS) was designated as a quality measure for endometrial cancer in 2014. However, national database analyses demonstrate that laparotomy is still performed for this indication. This study aims to assess the route of hysterectomy performed by gynecologic surgeons who manage endometrial cancer in the state of Florida.

Materials And Methods: All patients in Florida who were diagnosed with endometrial cancer (both ICD-9 Code 182.0 and ICD-10 Code C54.10), and who received a related surgical procedure from 2014 to 2016 were included. Eligible patients were identified using the Florida Inpatient Discharge Dataset, the Florida Ambulatory and Emergency Discharge Dataset, the Hospital Compare dataset, and the Healthcare Cost Report Information System. The primary surgeon was identified using their national provider identifier (NPI) number. Each surgeon's overall operative volume, MIS volume, and percentage of MIS procedures were collected.

Results: Hysterectomy for endometrial cancer was performed in 6086 patients; 4959 (81.5%) underwent MIS and 1127 (18.5%) had an abdominal approach. Hysterectomy for endometrial cancer was performed by 368 providers in Florida (range of 2-244 surgeries). The percentage of MIS to total hysterectomies for providers who performed 1-10 cases was 72.1%; 11-25 cases was 40.9%; 26-100 cases was 80.1%; and more than 100 cases was 86.1%. Variation in operative route exists amongst low- and high-volume providers.

Conclusions: Statewide databases can be used to identify surgical trends for policy purposes. These findings support the referral of patients with endometrial cancer to surgeons with high MIS volumes.
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December 2019

Rare case of a massive uterine arteriovenous fistula.

Am J Obstet Gynecol 2020 01 13;222(1):85-86. Epub 2019 Jun 13.

Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL.

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January 2020

Postoperative infections in women undergoing hysterectomy for benign indications: a cohort study.

Minerva Ginecol 2019 Aug 30;71(4):263-271. Epub 2019 May 30.

Department of Obstetrics and Gynecology, Denver Hospital, Denver, CO, USA.

Background: There is limited data on the incidence of postoperative infections following hysterectomy by route of surgery. We hypothesize that vaginal hysterectomy has lower rates of postoperative infection than laparoscopic and abdominal hysterectomies.

Methods: A retrospective cohort study and independent hand review of charts of participants undergoing hysterectomy at five hospitals from September 2011 through May 2015 was performed. Cases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes and were reviewed by the investigators. The primary outcome was the development of Clostridium difficile infection, urinary tract infection, surgical site infection, or yeast vaginitis within 60 days following surgery.

Results: In total, 2742 women underwent hysterectomy: abdominal 17.5% (AH), laparoscopic 65.8% (LH), and vaginal 16.7% (VH). The composite postoperative infection rate for the four specified variables was 8.5% (232). In comparing surgical route, AH was most commonly associated with CDI (0.6%, p <0.001), SSI (6.0%, P=0.001), and yeast vaginitis (1.9%, p <0.001), while VH was most commonly associated with UTI (8.1%, P=0.002). After controlling for demographic and operative factors, multivariable analysis showed that hysterectomy route was not associated with infection. Independent predictors for postoperative infection were increasing age, American Society of Anesthesiologists physical status classification, operative time, and hospital type.

Conclusions: Infectious complications after hysterectomy are uncommon, accounting for 8.5% of cases. Multivariable analysis showed that demographic and operative variables were more likely to serve as independent predictors of development of infection than hysterectomy route.
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August 2019

Radiation therapy is not an independent risk factor for decreased sexual function in women with gynecologic cancers.

Rep Pract Oncol Radiother 2018 Sep-Oct;23(5):331-336. Epub 2018 Aug 13.

Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO, USA.

Aim: To evaluate the associations of external beam radiation therapy (EBRT) and intracavitary brachytherapy (IB) with decreased sexual function.

Background: There's inconsistent evidence on whether radiation for gynecologic cancers has an impact on sexual health. IB, an underutilized treatment modality, is thought to have less adverse effects than EBRT.

Materials And Methods: A cross-sectional study examining decreased sexual function following radiation for gynecologic cancers. A decrease in sexual function was measured as a change in the Female Sexual Function Index (FSFI) from before to after treatment, with a significant decrease determined by Reliable Change Index Statistic (RCIS). Chi-square and -tests were employed.

Results: 171 women completed the survey; 35% ( = 60) received radiation, of whom 29 received EBRT and IB (48%), 15 EBRT alone (25%), 16 IB alone (27%). Women who received radiation had similar rates of decreased sexual function as women who did not (47% vs. 38%,  = 0.262). EBRT and IB had similar rates of decreased sexual function compared to women with no radiation (50% vs. 38%  = 0.166 and 47% vs. 38%  = 0.309). Women experiencing decreased sexual function were more likely to be under 50 years old (OR 5.4, 95%CI 1.6-18.1), have received chemotherapy (OR 5.7, 95%CI 1.4-22.9), and have cervical cancer (OR 7.8, 95%CI 2.1-28.8).

Conclusions: Treatment with EBRT or IB does not appear to impair sexual function in women with gynecologic cancer. Age less than 50, concurrent chemotherapy, and cervical cancer may place women with gynecologic cancer at higher risk for decreased sexual function following radiation.
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August 2018

Evaluation of Preoperative Chest Imaging in Low-Risk Endometrial Cancer Patients.

Int J Gynecol Cancer 2016 Feb;26(2):348-53

Department of Obstetrics and Gynecology, Denver School of Medicine, University of Colorado, Aurora, CO.

Objective: Current national guidelines recommend preoperative thoracic imaging for all patients undergoing surgery for endometrial cancer. The objective of this project was to report the incidence of pulmonary metastasis in endometrial cancer patients and describe tumor and patient characteristics to better identify a low-risk population for thoracic involvement. We evaluated the ideal modality of preoperative imaging for both low-risk and high-risk populations based on the risk of pulmonary involvement.

Methods: A retrospective cross-sectional study of patients undergoing surgical evaluation for endometrial cancer at a single institution from 2010 to 2014 was performed. Low-risk patients were defined as having a preoperative pathology sample showing grade 1 or 2 endometrioid endometrial cancer and a physical examination not concerning for extrauterine disease spread.

Results: A total of 352 patients were evaluated, of which 327 (92.9%) had preoperative thoracic imaging. Twenty-six patients had benign pathology or no preoperative sampling, leaving 301 patients for analysis. There were 228 (75.7%) of 301 patients classified as low-risk by our criteria. There were 20 (8.8%) of 228 low-risk patients with initial imaging concerning for pulmonary metastasis, but follow-up showed no evidence of disease. No low-risk patients (0/228; 95% confidence interval [CI], 0%-0.02%) had pulmonary metastasis. There were 4 (1.3%) of 301 (95% CI, 0%-0.04%) patients diagnosed with pulmonary metastasis based on preoperative imaging, and 4 (1.3%) of 301 (95% CI, 0.01%-0.04%) patients with recurrent pulmonary disease. Median time to pulmonary recurrence was 20 months.

Conclusions: The incidence of pulmonary metastasis found on preoperative imaging is exceptionally low in our defined low-risk population. All of the patients with pulmonary involvement either initially or upon recurrence had high-risk features. Given our findings, we would recommend that providers consider chest x-ray as the appropriate screening modality for the low-risk population and chest computed tomography for the high-risk population.
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February 2016